الفهرس 
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Abstract
Cardiovascular events remain the major cause of deaths among chronic kidney disease patients even after control of classic risk factors of CVD like hypertension, diabetes, hyperlipidemia, obesity, smoking and hypervolemia. So, we need to control nontraditional risk factors and target it to decrease morbidity and mortality of CVD among CKD patients.
Hypocalcemia, hyperphosphatemia and lack of vitamin D activation with CKD patient will lead to loss of negative feedback inhibition of parathyroid hormone synthesis which will lead to secondary hyperparathyroidism.
Therefore, hyperparathyroidism is a strong indicator of mineral abnormality in CKD patient.
Abnormalities of Calcium and phosphorus levels in CKD patients will lead to high incidence of calcification of the blood vessels and cardiac valves by several mechanisms: Calcium increase expression of (type3 sodium dependent phosphate cotransporter ) in the surface of smooth muscle of the blood vessels which will increase intracellular accumulation of phosphate ions which will lead to destruction of the extracellular membrane of the smooth muscle of the blood vessels which lead to deposition of calcium and phosphorus crystals and subsequent calcification which will lead to stenosis of coronary artery and stenosis of cardiac valves which will increase the cardiovascular events and complication; deficiency of systemic or local calcific inhibitor like fetuin- A and matrix Gla protein, damage of vascular smooth muscle cell and phenotypic transformation of VSMCs to osteo/chondrocytic cells. Tight
control of calcium and phosphorus level in CKD patients will decrease the cardiovascular events and complications.
We aimed to evaluate serum calcium and phosphorus level abnormalities in CKD patients and its relation to occurrence of ACS in those patients.
This study was conducted on 100 CKD patients with and without dialysis who admitted to Internal medicine department, Coronary Care Unit and nephrology unit of Sohag University Hospitals. The subjects were divided into two groups:
• CKD with ACS group: 45 CKD patients with and without dialysis and selected among those admitted in Coronary Care Unit in 6 months from (1/10/2021) to (31/3/202) with chest pain consistent with Acute coronary syndrome (ACS).
• CKD without ACS group: 55 CKD patient with and without dialysis were randomly selected among those admitted in Internal Medicine Department and patients on regular dialysis in nephrology unit with no history of ACS.
Summary of our results:
• Comparison between the two studied groups regarding demographic data. The mean age in CKD with ACS CKD with ACS group and CKD without ACS group were 57.56± 13.22 years and 49.13± 14.33 years respectively. There was statistically significant difference between the two groups regarding age (p=0.003) as age was significantly higher in CKD with ACS group compared to CKD without ACS group. Regarding gender, 55.6% cases were males and 44.4% were females in CKD with
ACS group while 58.2% cases were males and 41.8% were females in CKD without ACS group with no statistically significant difference between the two groups regarding gender (p>0.05).
• Comparison between the two studied groups regarding medical history. There was no statistically significant difference between the two groups regarding hypertension, DM, smoking status and family history of CAD.
• In CKD with ACS group, 8 (17.8%) patients had Anterior STEMI, 1 (2.2%) patient had extensive STEMI, 3 (6.8%) patients had inferior STEMI, 1 (2.2%) patient had MV replacement with UA, 16 (35.6%) patients had NSTEMI and 16 (35.6%) patients had unstable angina.
• There was significant elevation in calcium and phosphorus levels in CKD with ACS group compared to in CKD without ACS group (p=0.026 & 0.001 respectively).
• There was significant elevation in Calcium/Phosphorus ratio in CKD with ACS group compared to in CKD without ACS group (p=0.047).
• Comparison between studied groups regarding lipid profile. Serum cholesterol was significantly higher in CKD with ACS group compared to CKD without ACS group (p=0.006). Meanwhile, CKD with ACS group had significant decline in HDL when compared to CKD without ACS group (p=0.047). There was no significant differences between the two studied groups regarding triglyceride and LDL (p>0.05).
• Comparison between studied groups regarding kidney function tests. There was no significant differences between the two studied groups regarding serum creatinine, urea or eGFR.
• There was statistically significant difference between the two groups regarding PTH level (p<0.001) as it was significantly higher in CKD with ACS group compared to CKD without ACS group.
• Comparison between the two studied groups regarding cardiac markers. There was statistically significant difference between the two groups regarding troponin and CK-MB (p<0.001) as it was significantly higher in CKD with ACS group compared to CKD without ACS group.
• In CKD with ACS group, there was significant negative correlation between Calcium/Phosphorus ratio with serum phosphorus (r=- 0.892, p<0.001).
• in CKD with ACS group, there was significant negative correlation between Calcium/Phosphorus ratio with serum phosphorus (r=- 0.892, p<0.001). However, in CKD without ACS group, there was significant negative correlation between Calcium/Phosphorus ratio with serum phosphorus (r=-0.952, p<0.001), LDL (r=-0.316, p=0.025) and EF (r=-0.350, p=0.013). While, there was significant positive correlation between Calcium/Phosphorus ratio with serum calcium (r=0.367, p=0.009).
• ROC curve analysis shows that Calcium/Phosphorus ratio can predict acute coronary syndrome at cutoff 1.94 with area under the curve 0.652 with sensitivity and specificity was 77.8% and 52.1% respectively (p=0.007).
CONCLUSION
We concluded that there was significant elevation in calcium and phosphorus levels in CKD with ACS group compared to in CKD without ACS group. Calcium/Phosphorus ratio can predict acute coronary syndrome at cutoff 1.94 with area under the curve 0.652 with sensitivity and specificity was 77.8% and 52.1% respectively.
RECOMMENDATIONS
• At the same time, the pooled and meta-analyses for risk calculation did not require detailed clinical data
• Furthers prospective randomized multicenter studies with larger sample size is needed.
• More statistical analysis is required to validate the results.
• Long duration of follow up.